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TX insurance > definitions > Flashcards

definitions Flashcards

1
Q

What is an Administrative violation

A

A violation of the Texas Workers Compensation code or violation of any rule adopted under the same code that has resulted in, or could result in penalties or sanctions ordered by the Workers Compensation Commissioner.

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2
Q

What is an Agreement

A

resolution by the parties to a Workers’ Compensation dispute of one or more issues regarding an injury, death, coverage, compensability, or compensation. This term does not mean “settlement”.

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3
Q

What is an Alien

A

a person who is not a citizen of the United States.

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4
Q

What is a Benefit

A

a medical benefit, an income benefit, a death benefit, or a burial benefit based on a compensable injury.

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5
Q

What is case management

A

means a collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual’s health needs through communication and application of available resources to promote quality, cost-effective outcomes.

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6
Q

What is a Certified self-insurer

A

private employer granted a certificate of authority to self-insure for the payment of compensation.

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7
Q

What defines a child

A

means a son or daughter. The term includes an adopted child or a stepchild who is a dependent of the employee.

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8
Q

Define Commissioner

A

means the Commissioner of Workers’ Compensation.

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9
Q

What does Commute mean

A

to pay a lump sum. “Compensable injury” means an injury that arises out of and in the course and scope of employment for which compensation is payable by law. “Compensation” means payment of a benefit.

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10
Q

Course and scope of employment

A

means an activity of any kind or character that has to do with, and originates in the work, business, trade, or profession of the employer and that is performed by an employee while engaged in, or about, the furtherance of the affairs or business of the employer. The term includes an activity conducted on the premises of the employer or at other locations. The term does NOT include:
• Transportation to and from the place of employment unless:
o The transportation is furnished as a part of the contract of employment or is paid for by the employer;
o The means of the transportation are under the control of the employer; or
o The employee is directed in his / her employment to proceed from one place to another place.

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11
Q

What is Credentialing

A

the review, under nationally recognized standards to the extent that those standards do not conflict with other Texas laws, of qualifications and other relevant information relating to a health care provider who seeks a contract with a Workers’ Compensation Healthcare network.

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12
Q

Define Death benefit

A

payment made under Texas Workers’ Compensation rules, to a legal beneficiary because of the death of an employee.

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13
Q

Department means

A

the Texas Department of Insurance.

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14
Q

Designated doctor means

A

a doctor appointed by mutual agreement of the parties to a workers’ compensation claim, or by the Division, to recommend a resolution of a dispute as to the medical condition of an injured employee.

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15
Q

Define Disability

A

the inability, because of a compensable injury, to obtain and retain employment at wages equivalent to the preinjury wage.

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16
Q

Define Division

A

the “Division of Workers’ Compensation” within the Texas Department of Insurance.

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17
Q

Doctor means

A

a doctor of medicine, osteopathic medicine, optometry, dentistry, podiatry, or chiropractic who is licensed and authorized to practice. “Employer” means, unless otherwise specified, a person who makes a contract of hire, employs one or more employees, and carries workers’ compensation coverage. The term also includes a governmental entity that self-insures either individually or collectively.

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18
Q

Evidence-based medicine

A

the use of current best quality scientific and medical evidence formulated from credible scientific studies, including peer-reviewed medical literature and other current scientifically based texts, treatment and practice guidelines in making decisions about the care of individual patients.

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19
Q

Health care is defined as

A

including all reasonable and necessary medical aid, medical examinations, and medical services. The term does not include vocational rehabilitation.

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20
Q

Health care by TX definition includes

A
  • Medical, surgical, chiropractic, podiatric, optometric, dental, nursing, and physical therapy services provided by, or at the direction of, a doctor;
  • Physical rehabilitation services performed by a licensed occupational therapist provided by, or at the direction of a doctor;
  • Psychological services prescribed by a doctor;
  • The services of a hospital or other health care facility;
  • A prescription drug, medicine, or other remedy; and
  • A medical or surgical supply, appliance, brace, artificial member, or prosthetic or orthotic device, including the fitting of, change or repair to, or training in the use of the appliance, brace, member, or device.
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21
Q

Health care practitioner includes:

A
  • An individual who is adequately licensed and provides or renders health care; or
  • A non-licensed individual who provides or renders health care under the direction or supervision of a doctor.
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22
Q

Health care provider

A

means a health care facility or health care practitioner. “Health care reasonably required” means health care that is clinically appropriate and considered effective for the injured employee’s injury and provided in accordance with best practices consistent with:
• Evidence-based medicine; or
• If that evidence is not available, generally accepted standards of medical practice recognized in the medical community.

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23
Q

“Impairment” vs “Impairment rating”

A

Impairment means any anatomic or functional abnormality or loss existing after maximum medical improvement (MMI) that results from a compensable injury and is reasonably presumed to be permanent;
while Impairment RATING means the percentage of permanent impairment of the whole body resulting from a compensable injury.

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24
Q

Income benefit

A

a payment made to an employee for a compensable injury. This term does NOT include a medical benefit, death benefit, or burial benefit. “Independent review organization” means an entity that is certified by the Commissioner to conduct independent review under the rules adopted by the Commissioner.

25
Q

Injury

A

means damage or harm to the physical structure of the body and a disease or infection naturally resulting from the damage or harm. This term includes an occupational disease.

26
Q

Insurance carrier

A
  • An insurance company;
  • A certified self-insurer for workers’ compensation insurance;
  • A certified self-insurance group;
  • A governmental entity that self-insures, either individually or collectively.
27
Q

Insurance company

A

a person authorized and admitted by the Texas Department of Insurance to conduct insurance business in Texas under a certificate of authority that includes authorization to write workers’ compensation insurance. “Legal beneficiary” means a person entitled to receive a death benefit under Texas workers’ compensation regulations.

28
Q

“Maximum Medical Improvement” means the earlier of:

A

The earliest date after which, based on reasonable medical probability, further material recovery from, or lasting improvement to, an injury can no longer reasonably be anticipated.
• The expiration of 104 weeks from the date on which income benefits begin to accrue (also known as “statutory MMI”); or
• The date determined by the Commissioner to extend the 104-week limit because the injured employee has had, or is planning to have, spinal surgery. The Commissioner must make this ruling within 12 weeks before the expiration of the 104-week limit

29
Q

“Medical benefit” means payment for health care reasonably required by the nature of compensable injury intended to:

A
  • Cure or relieve the effects naturally resulting from the compensable injury, including reasonable expenses incurred by the employee for necessary treatment to cure and relieve the employee from the effects of an occupational disease before and after the employee knew, or should have known, the nature of the disability and its relationship to the employment;
  • Promote recovery; or
  • Enhance the ability of the employee to return to or retain employment.
30
Q

Objective

A

means independently verifiable or confirmable results that are based on recognized laboratory or diagnostic tests, or signs confirmable by physical examination.

31
Q

Occupational disease

A

a disease arising out of and in the course of employment that causes damage or harm to the physical structure of the body, including a repetitive trauma injury. The term includes a disease or infection that naturally results from the work-related disease. The term does not include an ordinary disease of life to which the general public is exposed outside of employment, unless that disease is incidental to a compensable injury or occupational disease.

32
Q

Research center means

A

means the research functions of the Texas Department of Insurance.

33
Q

Retrospective review

A

the utilization review process of reviewing the medical necessity and reasonableness of health care that has been provided to an injured employee.

34
Q

Treating doctor

A

the doctor who is primarily responsible for the employee’s health care for an injury.

35
Q

Violation

A

an administrative violation subject to penalties and sanctions as provided in the WC compensation code.

36
Q

“Workers’ compensation insurance coverage” means:

A
  • An approved insurance policy to secure the payment of compensation;
  • Coverage to secure the payment of compensation through self-insurance that complies with Texas laws and regulations;
  • Coverage provided by a governmental entity to secure the payment of compensation.
37
Q

“Utilization review”

A

includes a system for prospective, concurrent, or retrospective review of the medical necessity and appropriateness of health care services and a system for prospective, concurrent, or retrospective review to determine the experimental or investigational nature of health care services. The term does not include a review in response to an elective request for clarification of coverage.

38
Q

“Utilization review agent” means

A

an entity that conducts utilization review for:
• An employer with employees in Texas who are covered under a health benefit plan or health insurance policy;
• A payor; or
• An administrator holding a certificate of authority in Texas.

39
Q

Wages” includes

A

all forms of renumeration payable for a given period to an employee for personal services. The term includes the market value of board, lodging, laundry, fuel, and any other advantage that can be estimated in money that the employee receives from the employer as part of the employee’s renumeration. “

40
Q

“Network” or “Workers’ Compensation Health Care Network”

A

means an organization that is:
• Formed as a health care provider network to provide health care services to injured employees;

• Established by or operates under contract with an insurance carrier.

41
Q

“Objective clinical or laboratory findings”

A

means a medical finding of impairment resulting from a compensable injury, based on competent objective medical evidence that is independently confirmable by a doctor, including a designated doctor, without reliance on the subjective symptoms perceived by the employee.

42
Q

“Orthotic device”

A

means a custom-fitted or custom-fabricated medical device that is applied to a part of the human body to correct a deformity, improve function, or relieve symptoms related to a compensable injury or occupational disease.

43
Q

“Penalty” means

A

a fine established by the Commissioner.

44
Q

“Prosthetic device”

A

means an artificial device designed to replace, wholly or partly, an arm or leg.

45
Q

“Repetitive trauma injury”

A

means damage or harm to the physical structure of the body occurring as the result of repetitious, physically traumatic activities that occur over time and arise out of and in the course and scope of employment.

46
Q

“Representative

A

a person, including an attorney, authorized by the Commissioner to assist or represent an employee, a person claiming a death benefit, or an insurance carrier in a workers’ compensation matter arising that relates to the payment of compensation

47
Q

Sanction means

A

a penalty or other punitive action or remedy imposed by the Commissioner on an insurance carrier, representative, employee, employer, or health care provider for an act or omission in violation of Texas workers’ compensation laws, or a rule, order, or decision of the Commissioner.

48
Q

“Settlement”

A

means a final resolution of all the issues in a workers’ compensation claim that are permitted to be resolved by Texas workers’ compensation laws and regulations.

49
Q

“Subjective” means

A

perceivable only by an employee and not independently verifiable or confirmable by recognized laboratory or diagnostic tests or signs observable by physical examination.

50
Q

Employee includes

A
  • An employee employed in the usual course and scope of the employer’s business who is directed by the employer temporarily to perform services outside the usual course and scope of the employer’s business;
  • A person, other than an independent contractor or the employee of an independent contractor, who is engaged in construction, remodeling, or repair work for the employer at the premises of the employer; and
  • A person who is a trainee under the Texans Work program.
51
Q

each person in the service of another under a contract of hire, whether express or implied, or oral or written.

A

Employee

52
Q

The term “employee” does NOT include:

A
  • A master of or a seaman on a vessel engaged in interstate or foreign commerce; or
  • A person whose employment is not in the usual course and scope of the employer’s business. (401.012)
53
Q

• Not having the normal use of mental or physical faculties by reason of the introduction of alcohol, a controlled substance, a drug, a dangerous drug, a combination of two or more of those substances, or any other substance into the body; or • Having an alcohol concentration of 0.08 or more.

A

intoxicated- When a person makes the voluntary introduction into the body of any substance listed on the card, based on a blood test or urinalysis, it is a rebuttable presumption that a person is intoxicated and does not have the normal use of mental or physical faculties.

54
Q

The term “intoxication” does NOT include:

A

the loss of normal use of mental or physical faculties resulting from the introduction into the body of a substance:
• Taken under and in accordance with a prescription written for the employee by the employee’s doctor; or
• Taken by inhalation or absorption incidental to the employee’s work.

55
Q

Exempt employments

A
  • A person employed as a domestic worker or a casual worker engaged in a personal residence;
  • A person covered by a federal workers compensation law; or
  • A farm or ranch employee.
56
Q

Maximum vs Minimum weekly benefit

A

max benefits is set at $913.00. The minimum weekly benefit is set at 15% of the state average weekly wage, making the current minimum weekly benefit $137.00.

57
Q

Texas Labor Code sets the state average weekly wage (SAWW)

A

at 88%

58
Q

The average weekly wage of an employee who has worked for the employer for at least the 13 consecutive weeks immediately preceding an injury is computed by

A

dividing the sum of the wages paid in the 13 consecutive weeks immediately preceding the date of the injury by 13.

TX insurance (3 decks)

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